Housing the chronically homeless is Right Care in action

I've been a fan of Dr. Mitchell Katz, director of the safety net health care system in Los Angeles County, California, since reading his 2013 editorial arguing we should stop offering prostate-specific antigen screening because the substantial resources devoted to testing and subsequent diagnostic workups could be better utilized to provide high-value care. I had the chance to hear Dr. Katz speak in person a few weeks ago at the Lown Institute's Road to Right Care conference on another topic that I've written about before: providing supportive housing to chronically homeless persons.

As profiled in a feature article in the March/April issue of Mother Jones, the "Housing First" approach recognizes that many, if not most people who are chronically homeless struggle with mental illness or addiction. Both of these health problems, if inadequately treated, are likely to land patients in two of the most expensive temporary housing situations imaginable: hospital emergency rooms or prisons. Provided with a place to live and convenient access to counseling and health services, however, these individuals often thrive, at a fraction of the costs they would have incurred otherwise.

Housing First has been as successful in Salt Lake City as in New York City, and is now improving population health in Los Angeles. As Dr. Katz put it simply in his presentation, "There are a lot of chronic health problems that we can't cure. Chronic homelessness isn't one of them. Provide supportive housing. Problem cured."

An obstacle to implementing this strategy is resistance from local residents to the prospect of living next door to an apartment complex full of previously homeless people. And sometimes a suitable building is either too expensive to rent or just unavailable. One alternative approach is scattered-site housing, where clients are dispersed into housing units in multiple locations across a city. Until recently, though, we didn't know how well this would work. Earlier this month, JAMA published a randomized trial of scattered-site housing and case management services in four Canadian cities that found improved housing stability compared to usual care 24 months into the program. As the evidence accumulates, it is time to advocate for taking down bureaucratic barriers, Dr. Katz wrote in an accompanying editorial:

An important step toward substantially reducing chronic homelessness would be reimbursement for housing as a medical service for persons who are chronically ill and covered by Medicaid, Medicare, and private insurance. ... Clinicians who provide care for homeless persons are aware that they can order a variety of reimbursable tests and treatments for them, except the one intervention that most likely would make all the difference - supportive housing.

Created by the Affordable Care Act and chaired by the Surgeon General, the National Prevention Council is intended to coordinate federal prevention, health promotion, and public health activities across 20 different federal agencies, including several that are not traditionally thought of as being health-related but have significant influences on health. A strong recommendation from the Prevention Council to Congress supporting the addition of housing as a preventive service that saves money and improves health outcomes might actually be something both political parties could get behind.

Patients: steer clear of these six orthopedic procedures

After the American Academy of Orthopaedic Surgeons (AAOS) released its Choosing Wisely list, it was criticized for selecting items that are uncommonly used or have little effect on the income of its members. In an editorial in the New England Journal of Medicine, Dr. Nancy Morden and colleagues pointed out that the five services listed by this specialty group were particularly "low impact":

The American Academy of Orthopaedic Surgeons named use of an over-the-counter supplement [glucosamine and chondroitin] as one of the top practices to question. It similarly listed two small durable-medical-equipment items and a rare, minor procedure (needle lavage for osteoarthritis of the knee). Strikingly, no major procedures — the source of orthopedic surgeons' revenue — appear on the list, though documented wide variation in elective knee replacement and arthroscopy among Medicare beneficiaries suggests that some surgeries might have been appropriate for inclusion.

At the Lown Institute's recent "Road to Right Care" conference, a group of orthopedic surgeons identified five other procedures that, in contrast to the AAOS list, are frequently performed at great expense in the U.S. but provide little or no benefit to patients.

1) Vertebroplasty for spinal compression fractures - in two randomized controlled trials comparing vertebroplasty to a sham procedure, there were no differences in pain or quality of life between the intervention and control groups. Risks of vertebroplasty include causing compression fractures in adjacent vertebrae, dural tears, osteomyelitis, cement migration, and radiculopathies requiring subsequent surgery.

2) Rotator cuff repair for non-traumatic tears in older adults - A randomized trial comparing physical therapy, physical therapy plus acromioplasty, and physical therapy plus acromioplasty and rotator cuff repair found no differences between the control and surgery groups after one year. About 600,000 Americans undergo rotator cuff surgery every year.

3) Clavicle fracture plating in adolescents - In adolescents with clavicle fractures that were displaced and shortened, there were no differences between nonoperative management (a sling for the affected arm) and surgery in appearance, range of motion, or participation in sports activity two years after the injury. However, 1 in 4 adolescents who underwent surgery required re-operation for surgical complications.

4) Anterior cruciate ligament (ACL) reconstruction - In young, active adults with acute ACL tears, a randomized trial comparing early (within 10 weeks of the injury) ACL reconstructive surgery plus physical rehabilitation to rehabilitation plus optional delayed reconstruction up to 2 years after the injury found similar outcomes between the groups. 61 percent of the optional reconstruction group did not require surgery. More than 100,000 ACL reconstructions are performed in the U.S. each year.

5) Partial medial meniscectomy for adults with knee osteoarthritis and no mechanical symptoms - A randomized trial found no benefit of partial meniscectomy compared to sham surgery in adults with degenerative meniscal tears and no osteoarthritis. A systematic review of 7 trials came to the same conclusion. In adults with osteoarthritis, surgery plus physical therapy was not more effective than physical therapy alone. Arthroscopic partial meniscectomy is the most commonly performed orthopedic procedure in the U.S., with 700,000 operations annually.

Finally, a randomized trial just published in JAMA suggested that another procedure whose use is increasing worldwide provides no benefits.

6) Surgery for adults with displaced proximal humerus fractures - Patients who underwent fracture fixation or humeral head replacement within 3 weeks of sustaining a displaced fracture of the proximal humerus had no better outcomes than patients assigned to nonoperative management (sling immobilization) after 2 years.

What accounts for the continued popularity of ineffective orthopedic procedures? Excessive magnetic resonance imaging (MRI) plays a role; immediate MRI is rarely indicated for common musculoskeletal conditions, and may often provide deceptive or confusing results, such as identifying meniscal tears that are unlikely to be the cause of patients' chronic knee pain. Some primary care clinicians' lack of comfort with the orthopedic examination may lead to unnecessary referrals. Patients who perceive surgery to be a "quick fix" may not have the patience to stick with physical therapy and rehabilitation. And there is the inescapable reality that, necessary or not, these procedures pay well.

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This post first appeared on the AFP Community Blog.

Overdiagnosis and the epidemic of snipers on rooftops

A 2013 editorial written by two oncologists in the Annals of Internal Medicine discussed overdiagnosis, a controversial health problem that some have called "a modern epidemic" but others, including the editorialists, feel is a minor concern. Although many chronic conditions are overdiagnosed, cancer is the most thoroughly studied, as well as the most emotionally charged.

I am a generally healthy man with no family history of significant health problems. Yet increasing numbers of men like me who are approaching middle age may be shadowed by a sniper on a rooftop, each armed with a highly accurate loaded rifle pointed directly at our heads. By age 70, nearly half of all men will be shadowed by a sniper, though in only 3 percent of us will he actually take the fatal shot. A 1 in 30 chance of being assassinated without warning still seems too high, and therefore health authorities concerned about the problem of snipers on rooftops recommend that all men after age 50 (or perhaps 40) be offered routine surveillance to determine if there's a sniper up there. If there is, perhaps he can be safely disarmed.

The  trouble is, the disarmament team is successful at best, 21 percent of the time (reducing a man's chance of being shot from 3 percent to a barely more reassuring 2.4 percent), and at worst, hardly ever. In addition, attempts to subdue snipers by force often lead to unwanted consequences: stray shots fired in the scuffle that cause non-lethal but persistent injuries to the bladder and reproductive system. In about 1 in 300 men, the attempt to disarm the sniper goes terribly wrong, causing the gunshot to miss the head but deliver an equally fatal round through the heart.

Oncologists and others whose careers primarily consist of treating cancer argue that the true problem is not one of overdiagnosis but overtreatment, and that a more conservative approach to management (rather than less diagnosing) of indolent cancers will solve the problem. Let's not rush in to disarm all of the snipers, they say - instead, let's watch them for signs of aggressiveness and act later if necessary (termed "watchful waiting" or "active surveillance"). Men who choose this option live the rest of their lives with the anxiety-provoking knowledge that guns are pointed at their heads, however small the possibility of a shot. They and their physicians may become so obsessed with the sniper, constantly scanning the tops of tall buildings, that they forget to look both ways when crossing the street and succumb to some other preventable cause of death.

A reasonable objection to my analogy of the sniper on the rooftop is that unlike a bullet to the head, death from cancer is neither quick nor painless. By measuring deaths averted as a primary outcome, the argument continues, one minimizes the benefit of sparing patients the symptoms and treatment of metastatic disease. This argument only holds in cases when cancer was destined to progress enough to cause symptoms (not overdiagnosed). I don't discount it, having witnessed firsthand the suffering that metastatic prostate cancer inflicts on patients, but cancer is hardly unique in this regard. There is, unfortunately, a great deal of suffering involved in slow deaths from non-cancerous causes such as congestive heart failure, chronic obstructive pulmonary disease, multi-infarct or Alzheimer's dementia. To be worth the price of overdiagnosis, cancer screening should do more than replace one cause of death for another.

Back to the Annals editorial about overdiagnosis in breast cancer. The authors wrote:

We believe that the term "overdiagnosis" in the context of breast cancer places this problem in an inappropriate light, suggesting that these patients do not have cancer. The question is not whether we should find early, more easily treatable cases of breast cancer but rather how to treat early-stage cancer found on mammography. ... For the individual patient, the question is not whether to have a mammogram that might "overdiagnose" breast cancer but how to treat the early-diagnosed non-invasive or invasive breast cancer once we have found it.

Essentially, this boils down to: overdiagnosis be damned, let's find all of the cancers we can, and then worry about what to do about them later. (Let's find every single one of those snipers on the rooftops and then decide if and when they should be disarmed!) On the contrary, I believe that individual women (and men, in the case of prostate cancer) should be presented statistical information about overdiagnosis along with potential benefits and then offered a choice, rather than a default option. Some - perhaps most - women will choose to be screened, despite evidence that more than 3 in 10 breast cancers are overdiagnosed. Others will not. The latter should have their choices respected, rather than be harangued or fired.

Finally, I apologize for this explicit comparison of overdiagnosis to gun violence, which is a formidable public health issue of its own. Although not as immediately devastating or newsworthy, overdiagnosis is a public health problem in its own right, an epidemic that has affected millions of men and women over the past few decades in cancer alone. It deserves attention, not dismissal, in the pages of major medical journals.

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A slightly different version of this post first appeared on Common Sense Family Doctor on January 2, 2013.

ACC/AHA and Framingham calculators overestimate cardiovascular risk

After more than a decade of titrating medications to low density lipoprotein cholesterol targets, family physicians who have transitioned to the 2013 American College of Cardiology / American Heart Association cholesterol treatment guideline now base treatment decisions on a patient's estimated 10-year risk for a cardiovascular event. Although it endorsed the ACC/AHA guideline last year, the American Academy of Family Physicians expressed concern that the guideline's new risk calculator had not been validated in contemporary U.S. populations and could potentially overestimate risk compared to the venerable Framingham calculator.

An analysis published in the Annals of Internal Medicine compared predicted risk scores from the ACC/AHA calculator and four other cardiovascular risk calculators (three derived from the Framingham Heart study) to actual cardiovascular events observed in the Multi-Ethnic Study of Atherosclerosis (MESA), a diverse cohort of adults recruited from six U.S. communities in 2000 to 2002 and followed for ten years. The authors found that both the ACC/AHA and Framingham-derived risk calculators overestimated cardiovascular risk by 37 to 154 percent in men and 8 to 67 percent in women. The Reynolds Risk Score, which includes a measurement of high-sensitivity C-reactive protein, was the most accurate at predicting cardiovascular risk in the MESA cohort, underestimating events by 3 percent overall.

A previous American Family Physician editorial criticized the ACC/AHA guideline for recommending a statin for primary prevention in patients with 7.5 percent 10-year cardiovascular risk, noting that personal estimates of potential benefits of statin therapy relied on a calculator with a "nontrivial margin of error." Nontrivial, indeed. The Annals analysis found that men in the MESA cohort with a calculated ACC/AHA risk score of 7.5 to 10 percent had an actual event rate of only 3 percent; and just over 5 percent of women with a similar risk score experienced cardiovascular events.

Although statins appear to reduce the risk of future cardiovascular events by the same relative proportions in high-risk and low-risk populations, lower-risk patients will experience lower absolute benefits that may not be outweighed by the inconvenience, expense, and potential side effects of therapy. Compounding this problem, a recent systematic review found that most patients already overestimate treatment benefits and underestimate harms. This new analysis won't lead me to abandon cardiovascular risk calculators, but going forward (or until better ones are developed) I plan to acknowledge their lack of precision in discussions with patients, especially those on the lower end of the range of risk where statins are recommended.

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This post first appeared on the AFP Community Blog.

We need to know more about psychological harms of screening

Several years ago, a few colleagues and I performed a systematic evidence review to help update the U.S. Preventive Services Task Force's recommendations on screening for prostate cancer. One of our key questions asked about the harms associated with prostate cancer screening, other than the overdiagnosis (and resulting unnecessary treatment) of clinically insignificant tumors. Since routine prostate-specific antigen screening had been going on for nearly two decades by then, we expected to find plenty of studies measuring anxiety and other mental health changes caused by false positive or indeterminate screening results.

In fact, after sifting through more than four hundred citations, we only found four articles describing three studies. Only one of the studies followed men for as long as one year. Here's what we wrote about that study:

[The authors] compared 167 men who had an abnormal screening result but a benign biopsy specimen with 233 men who had a normal PSA level. After 6 weeks, 49% of men in the biopsy group reported thinking about prostate cancer “a lot” or “some of the time,” compared with 18% of the control group. In addition, 40% of the biopsy group worried “a lot” or “some of the time” about developing prostate cancer compared with 8% of the control group. ... Statistically significant differences between the biopsy and control groups in anxiety related to prostate cancer and perceived prostate cancer risk persisted 6 months and 1 year later.

One might think that men with normal biopsies following an elevated PSA level should have been reassured that they had dodged a bullet and been pronounced prostate cancer-free. In fact, exactly the opposite occurred. And that's hardly surprising, since prostate biopsies, unlike breast biopsies, usually don't aim for a particular location of concern, leaving open the worrisome possibility that the biopsy needle just didn't sample the cancer if it was there. (How uncommonly cancer cells found in the prostate spread and lead to symptoms or death is another issue entirely.)

In the seven years since that review was published, the USPSTF has recommended against PSA-based screening for prostate cancer and recommended for low-dose CT screening for lung cancer in selected patients. There has been a major shift in how scientists view cancer screening and more interest in studying previously undescribed harms. In a review of psychological harms of screening published in the Journal of General Internal Medicine, Dr. Jessica DeFrank and colleagues assessed the literature on the burden or frequency of psychological harm associated with screening for prostate cancer (42 studies), lung cancer (11 studies), osteoporosis (6 studies), abdominal aortic aneurysm (8 studies), and carotid artery stenosis (1 study). They observed that for most screening tests, there remain large gaps in the evidence about the magnitude and frequency of such harms in populations representative of those receiving the tests. (I hasten to add that neither the USPSTF nor any other legitimate medical organization recommends ultrasound screening for carotid artery stenosis.) 

Causing someone needless worry about cancer or another absent health condition can seem trivial compared to the prospect of saving a life. But increasing recognition of the limitations of screening for cancer and disease in general, and the nearly nonexistent effect of these tests on all-cause mortality, have altered the equation. If more than 96 percent of initially positive screens turn out to be false positives (as is the case for lung cancer screening), just how much anxiety and worry are we as a society willing to inflict to merely exchange one cause of death for another?

Two types of "scut work"

When I was an acting Medicine intern in Manhattan's Bellevue Hospital at the turn of the century, all employees who provided the hospital's "ancillary services" went home between the hours of 5 PM and 8 AM. It was the job of the on-call interns to fill in. If a patient needed a stat blood draw or IV line replacement in the middle of the night, his nurse paged the intern to do it. If I wanted a vial of blood to reach the lab before the morning, the only way to accomplish this was to carry it there myself. If a patient needed an urgent x-ray or CT scan, I personally navigated his or her stretcher from room to elevator and through the corridors to Radiology. (Even during daytime hours, this was often the most efficient way to complete this task.) In those days when x-rays and scans were actually printed on sheets of transparent plastic and stored in file folders, it was also the intern's job to hunt down images needed for morning rounds.

Generations of doctors-in-training have given the name "scut work" to these kinds of tedious, often disagreeable chores that do not require a doctor's degree but are nonetheless essential to patient care. More than a decade later, interns and residents continue to toil at similar unrewarding tasks in hospitals all over the U.S. and around the world.

But scut has evolved in the era of electronic medical records to mean more than late-night blood draws and transporting patients and medical records. Scut work is now performed by physicians with decades of post-residency experience, at all hours, in outpatient and inpatient practices. It goes by important-sounding names: "Stage 2 Meaningful Use" or "NCQA Certified Patient Centered Medical Home." Specific tasks involve clicking through endless series of drop-down boxes to document smoking cessation counseling, order flu shots and age-appropriate cancer screenings, and record transitions of care and receipt of referral notes. These are all things that I would have documented in a free-text or dictated note, but must now jump through electronic hoops to get credit from private and public payers who believe that primary care patients will ultimately benefit from all this clicking even as it distracts my and my colleagues' attention away from the real work of doctoring.

In an editorial in Annals of Internal Medicine, Drs. Christine Sinsky and John Beasley argued that "texting while doctoring" is a potential patient safety hazard:

In clinics across the country we have observed patients send signals of depression, disagreement, and lack of understanding and have witnessed kind, compassionate, and well-intended physicians missing these signals while they multitask. These physicians are concentrating not only on the patient but on typing the history, checking boxes, performing order entry, and other electronic tasks. ... Computerized order entry displaces to the physician clerical tasks once performed by others, increasing time commitment and cognitive interruptions.

The authors suggested that supporting team-based care models that rely on non-physicians to do the bulk of documentation may still save the physician-patient interaction. But this is unlikely to happen if physicians are required by federal regulators to type in orders themselves, or if new payment schemes do not rapidly supplant fee-for-service and render current billing templates obsolete.

In contrast, Dr. Diane Chang described old-school scut work in JAMA's "A Piece of My Mind" as "the physical, backbreaking, day-to-day work of taking care of another person." She shared scenes of doctors, nurses, aides, and other health workers debriding infected ulcers, cleaning up vomit and feces, feeding and bathing and changing beds. "Acts of caring are sacred: feeding the sick and old, cleaning them, and tending to their wounds are in some ways as intimate as you can get with another body," she wrote. "In performing these acts, we bear witness to people naked and infirm, at the beginning of life or at the very end, or at the most vulnerable moments in their lives."

I don't want to go back to my days of doing scut at Bellevue. I am not nostalgic about trying repeatedly to place an 18-gauge IV in a patient with no palpable veins at four in the morning, or replacing a delirious patient's nasogastric tube for the fifth time in as many hours because he kept pulling it out. But at least that kind of scut, unlike the tedious tasks involved in electronic documentation, was work that was meaningful to patients.

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This post first appeared on Common Sense Family Doctor on December 16, 2013.